The patient experience: 4 observations from a physician

Last year, I retired from full-time practice and moved to a new area. At about the same time, my wife was diagnosed with breast cancer, and because she was in good health prior, she had relatively little contact with the health care system as a patient.

Before our move she worked as a part-time school nurse, so we were able to share provider horror stories from different perspectives. Since we moved to a new area, none of the providers knew us, so we went from being providers to consumers of health care.

I also decided to not identify myself as a physician and my wife as a nurse unless asked so we could experience what it’s like to be a typical patient interacting with the health care system.

Although our experience has been good, we could see why many patients are frustrated. The question is, who is to blame? Either health care is as incompetent, greedy and cold, as many believe it is, or health care is trying to adjust to changes that are being imposed from the outside.

Our verdict: 5 percent the former, 95 percent the latter. The vast majority of providers are motivated to try and do the right thing but are being hampered by outside forces that are either well-intentioned but ignorant, or are politically motivated. Couple this with extreme reluctance on the part of providers and their representatives to resist these outside changes and one has to wonder why things are not much worse. Here is a short list of what we have observed:

1. The “we really have no clue why health care costs so much” approach to health care financing and cost. Providers are bearing the brunt of a backlash caused by a third party payor system, including the government, that is both complex and confusing. Very few patients understand the intricacies of insurance, co-pays, and deductibles. They only see that their premiums are going up.

More than once we would be sitting in a waiting area when a patient would yell at the front office staff about their co-pay. The reaction of the other waiting patients would run from “rich doctors” to “greedy insurance companies” to “impeach the president.” I remember one of my wife’s providers almost having a meltdown because she had to tell my wife that she needed a procedure and was worried about the cost and how relieved she was when we told her we had met our deductible.

Next year when the full effect of the ACA hits the average citizens premiums I’m certain the providers will get the blame for that as well.

2. The not ready for prime time EMR push. Especially in the pre-op area, half of the providers time was spent on dealing with entering data into the computer or dealing with software that did not work at all. This took their attention away from true patient care and clearly left them harried.

One day, my wife noticed that her IV had been left wide open and drained out completely. When she pointed it out to them, they nearly went into a panic. Also, there were times when there would be a harried nurse attempting to get my wife ready for surgery and another harried nurse would continually come into our bay begging our nurse to help them with their computer. One way or another it did not look good.

3. The Chicken Little approach to patient safety. Ironically, efforts to improve patient safety have left the impression that providers are incompetent. Every time my wife was handed off to someone else there was a ritual where the person had to check the ID band, ask the patient’s name, the birthdate and what procedure was being done. After about the fourth time this is done is it any wonder that the average patient would question if these people knew what they were doing. The “only the surgeon can verify the surgical site” approach has also slowed things down considerably.

4. The “treat the patient survey, not the patient” approach. Clearly, a poor patient survey has become like kryptonite to health care providers. The smart providers are learning how to play the game because of the supposed link between patient surveys and the push toward quality care. Sometimes the reaction is benign, such as lavish waiting areas, but patient care is clearly being affected.

The push toward simple, streamlined care such as surgicenters and urgent care centers that attract the simplest, and most compliant patients will continue unabated.

From our perspective we noticed that if we did not fill out the patient survey right away we were continually asked to do so. Have the smart providers learned that, left to themselves, a patient is much more likely to complete a “poor” survey then a “good” survey? So by harassing everyone they can up their averages to get as close to the coveted 5-star rating as possible? Perhaps.

These observations are not mutually exclusive and tend to feed on each other. Perhaps the panic over the IV running out was caused by fear of getting a poor review. The panic buying of an inadequate EMR system is the result of a tight budget and resultant desperate fear of not getting any meaningful use money, or worse, an actual cut in Medicare reimbursement.

For whatever reason, from the patients’ perspective, what we are doing is not working.

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The patient experience: 4 observations from a physician 90 comments

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Patient Kit

Despite receiving more medical care in the past few years than I have in the whole rest of my life, I have not yet been asked by any doctor or hospital to complete a patient satisfaction survey. It’s mystifying. I’ve heard plenty about these surveys here but have never been asked to do one, which is unfortunate since I have mostly good things to say about my docs. I hope your wife is doing well.

Thomas D Guastavino

My wife is doing fine, thank you. Give it enough time and you will get a survey.

Vic Nicholls

I’m glad for you. I know those where it didn’t. Horrible.

Vic Nicholls

Agreed. Know too many with BC. Horrible. 🙁

FinnHaddie

I’ve only rarely been asked to complete a survey, and never on site; they get mailed to me at home.

Katz

I just saw an ortho for knee pain–my first doctor visit in years. I never had knee problems before, and still have no idea what caused it or how to get rid of it–the whole point of seeing him, in my opinion. For the $265 Medicare paid, I doubt he was in the room 10 minutes. A clerk or nurse of some sort did the typing before he, himself, appeared. She had a generic badge that just said ‘medical staff.’ I asked her pointedly, exactly what sort of staff she was. She replied, “I’m medical staff.”

The doctor turned out to be beefy young guy who seemed accustomed to treating other beefy young jocks, not old ladies. He glanced at the X-rays, announced I didn’t have arthritis, needed PT, and ran before I could ask any questions. I don’t know what his hurry was. I was the only patient in the office.

Immediately, the survey appeared in my e-mail. Each section had identical questions, about how did I like the decor (?), did I receive service with a smile? (Do you want fries with that?) I skipped to the end and commented that the survey was idiotic and had no questions pertinent to actual medical care. I could care less whether the fake paintings match the sofas, and how much the secretary groveled. My knee still hurts…

Thomas D Guastavino

As I said, providers are being distracted from what is important.

Captain Lurk

So, you disagree with an experienced orthopedic surgeon about the state of medicine. Well I, for one, am convinced by your arguments.

Thomas D Guastavino

The reality is that the systems we are using are concentrating on the wrong things, so much so that other things are being ignored. “Better safe then sorry” is more like “Penny wise and pound foolish”

W. X. Wall

This is an important point. While focusing on process to improve results can be useful (e.g. six sigma techniques), focusing on the *wrong* processes and/or results just wastes energy. And that’s, unfortunately, what much of the process improvement in medicine focuses on these days.

Why? Firstly, the goals between players are not aligned. Between patients, physicians, administrators, lawyers, insurance companies, and govt agencies, there are a wealth of conflicting goals. Which ones get addressed is more a function of political strength than a rational balancing of competing interests.

Secondly, the increased complexity of managing a large organization is only worth it if those costs are outweighed by efficiencies of scale. There is precious little efficiency of scale in delivering medical services. Aside from the capital efficiency of aggregating expensive equipment (e.g. O.R.’s), the actual productivity of a physical interaction between a provider (be it doctor, nurse, therapist, etc.) and a patient does not go up if you have a hundred people doing it. This means providers are facing all the downsides of organizational complexity with none of the upside of increased productivity for their tasks. Of course, health care organizations are consolidating for other reasons, namely increased power to structure the marketplace to their advantage vis-a-vis their competitors, but we providers are the ones forced to bear the brunt of that process without deriving any benefit from it.

Finally, IMHO, the people analyzing and “improving” these processes know very little about them. I can’t tell you how often I’ve heard health policy types, administrators, etc. say something so asinine that I wonder if we’re talking about the same industry. In the military, no one becomes a General unless they’ve commanded combat troops, usually in different tasks, plus have rotated through a bunch of different specialties and posts (thus the reason they’re called “general staff”). Anyone in the military who expects to formulate strategy without ever leading combat troops through the dirt would be laughed out of the office (and even with that, many in the military would say many Generals are still clueless). And yet that’s exactly what happens in healthcare.

So combine conflicting goals with decreasing efficiency / increasing complexity of implementing those goals, all with “leaders” who rarely set foot in a hospital outside its posh offices, and you have an organization that is hardly equipped to focus on true process improvement.

RenegadeRN

I like your general analogy.

Vic Nicholls

Yes whether or not I agree I liked your post. The second paragraph was right on, especially. Well written and thought out.

Thomas D Guastavino

Agreed. We took a system with essentially a flat tire and messed up the brakes and the engine trying to “fix” it.

exit 7

Oh Honey, it was way worse than a flat tire. You’re right though, we made it worse.

Thomas D Guastavino

You are welcome to use whatever analogy you wish.

Vic Nicholls

I’ve seen more problems out of not fixing systems and the doctors themselves. Admin and lawyers do nothing about either one except to protect them, use gag clauses, and hide things rather than sitting down and addressing the problems. That includes doctor egos, which is one the biggest impediments to change. A million dollar doctor gets a pass to dump on their colleagues when they can’t provide the experience they advertise. That is the sort of thing that is not a system problem, because the doctor should have been fixed BEFORE it became a system problem.

Thomas D Guastavino

And how exactly would you “fix the system and the doctors themselves”? Its not enough to just complain about something. You have to first understand whats wrong then come up with a solution that makes sense. If you don’t you just make the problem worse which is what is happening to health care today.

Vic Nicholls

Take responsibility & that doesn’t include lawyering up, threatening, harrassing, behavior. Sit down and act like mature adults, work together to better outcomes. You will quickly figure out when patients and/or doctors are not emotionally intelligent and mature. Get rid of 1/2 the admin and 3/4 of the risk managers. Another 1/4 of the admin put them back into floor nursing/doctoring and let them be like other doctors on the firing line. More transparency. No more gag orders. Cap admin salaries. That’s for starters.

Thomas D Guastavino

Now Im confused. Are you blaming the doctors for what it is going on or are you agreeing with me that the problems in health care are being caused by ill-advised outside forces that have no clue how to “fix” health care?

Vic Nicholls

Doctors are to blame for poor care, egos that interfere with patient care, lack of evidence based medicine that causes harm to patients, etc. The admin are to blame for business/$$$ over patients, and for supporting doctors that need to be exposed to the repercussions of their mistakes. There are outside forces that do know how to fix health care, there are forces inside it. The indication you have is that doctors have the answers. Some do, some don’t. Some admin do, some don’t.

I think what people failed to point out to you in a few words is that the attitude you come off with on the boards is not one that the general public now is willing to accept or would make them want them to come to the table and be an equal partner with. The impressions you give aren’t condusive to an equal relationship.

Thomas D Guastavino

Since you threw down the gauntlet about my “attitude on the boards” lets see exactly who is being unreasonable about being an “equal partner”. You made a blanket negative statement saying “Doctors are to blame for poor care, etc.” You have come to the table with a very negative few of doctors and you blame us for the mistrust? Before we proceed with our “negotiations” you need to either retract what you said or clarify. The we can talk about solutions

exit 7

Sorry. It’s not the doctors to blame for poor health care. Do you work inside our healthcare system? Doctors haven’t gotten worse, but your insurance has, the profit margin of corporate healthcare is nuts. The profit margin of your prescription manufacturer is crazy. DME providers? They’re making out like bandits. And all these folks have nice little PR and marketing firms working for them. People are declaring battle on the frontline. That’s not effective and will never fix our system, one that is becoming more broken every day.

Vic Nicholls

When a doctor makes a decision to ignore signs, symptoms, bloodwork, medication responses, etc. that is poor health care. When they ignore medical research, that is poor health care. Refusing to work with other specialists on a patient: doctor.

I don’t disagree there are problems with admin. That is why I made the comment about 1/2 of admin, 3/4 of lawyers to go.

Thomas D Guastavino

Agree with many of these but please say “unsatisfactory medical evaluation and control system”. These have little to do with the “medical system”

Thomas D Guastavino

If you are referring to the term “providers” I actually like the term. As it turns out the providers (physicians, nurses, PAs, NPs etc.) are the ones being negatively effected by the non-providers (administrators, insurance carriers, government watchdogs, quality assurance and creators of protocols,etc…..etc…..etc.) so the provider, non-provider distinction is appropriate.

Patient Kit

That’s an interesting take on the “provider” term. When you compare it to the non-providers, that’s a whole new perspective. I usually think of it as an easy way for the business powers that be of medicine (the non-providers) to lump docs, nurses, PAs, etc alll together and label you in a more business-oriented way. But it is certainly preferrable to being called a non-provider. I still object to being called a customer or consumer instead of a patient. But it’s better than being called an impatient. 😉

MuscleSpasm

I also object to being called a customer/consumer. It implies that the patient has control over the situation and that health care operates under the free market system, which it doesn’t.

SherryH

I understand what you are saying, however, many of us feel differently. If you don’t need or want prices, that is fine, but there are many of us who do. I have musculoskeletal pain and a high deductible, high copay plan. There is a big difference between a $400 MRI and a $1400 MRI, and $350 physical therapy session and $60 session. If I didn’t price shop at all I would be literally bankrupt. As is, I almost am from lack of transparency on prices, even though I try. There is no reason why patients can’t get real answers about stagnant things like medical supplies, appointments, small procedures, tests, etc. other than the unethical pricing system we have in place. It’s ok that you don’t want those prices, but I do.

Thomas D Guastavino

I understand what you are saying but I don’t believe price shopping is going to help that much. First, most insurance plans have done the price shopping by picking their “in network” providers. This also applies to your “in network”deductible. Second, what happens with emergency care? Not exactly the best time to be arguing price. Lastly, what happens if your provider recommends something and you don’t want to do it because it “costs to much”? You can certainly argue whether or not it is necessary purely on a medical basis or whether a cheaper alternative is just as good but what happens if the test or procedure is clearly medically indicated and the only issue is price? If you are willing take the risk that is certainly your prerogative but then don’t blame the provider if something goes wrong.

SherryH

I certainly never mentioned emergency services, only stagnant services. Emergency services are a different issue all together. Have I said no to something because I couldn’t afford it? The answer is yes, although nothing I said no to was an emergency. If prices for certain things weren’t so outrageous, this might be easier. I mean seriously, $350 for one physical therapy session, $400 for a walking boot I can get at a medical supply store for $60? Why shouldn’t I be able to find honest answers on these prices and shop around?

Thomas D Guastavino

I congratulate you on doing your homework. If you can get the walking boot for $60, assuming it fits your needs and is acceptable by your provider, go right ahead. As far as the PT is concerned, as I said your insurance carrier has likely done the screening for you. In fact, rather then “shop around” I would recommend seeing if you can do your own PT first and I would bet you would be a very cooperative patient and a pleasure to work with. Other patients are not so cooperative and motivation is a big problem.

SherryH

After several days of phone calls I was able to get a list of physical therapy facilities that charge a copay for a health appointment instead of unknown/gotcha outpatient prices. Insurance approved me for a specific number of appointments and that is what I have agreed to go to, I also do my own at home. After I am out of appointments, I will just do everything at home, I don’t think I will be better, but I don’t really have a choice. Even at this price it will cost hundreds. And you are right about motivation, I do them because I want to swim again, but I can see that as being a factor.

Thomas D Guastavino

As I said, I congratulate you on doing your due diligence and your motivation.

Patient Kit

I’ve been through several orthopedic injuries that required PT after surgery. I’ve been lucky to have had both good physical therapists and insurance that paid for PT with no copay. I’ve always been happy to be able to get myself off 3x week PT sessions after the more acute rehab stage and move on to continuing my own PT at home and at my local Y on my own schedule. My motivation for continuing PT beyond formal PT sessions was that I wanted to be able to walk again. Even though PT was like having a personal trainer, I couldn’t wait to move past a rigid PT schedule even when it didn’t save me any money personally. But during the most acute post-surgery weeks, I could easily have done some real harm without the guidance of good trained PTs. They are not all the same any more than docs are all the same.

HJ

So how do you decide that the $60 physical therapy session is not inferior to the $360 PT session? Maybe the $60 PT session doesn’t solve your problem and you spend years of pain and an additional MRI while the $360 PT solves your problem in a short time period?

And do you understand the difference with the quality of the MRI? Perhaps that $400 doesn’t reveal the true nature of your problem while the $1400 MRI gives you an accurate diagnosis.

MuscleSpasm

Please, an MRI is an MRI. Cost only depends on the place where you have it, hospital systems can and will charge you more, higher cost does not mean higher quality in this case. Same with the PT. I have had PT several times at several different locations, higher cost is just that, higher cost.

RenegadeRN

Hope I never have to go under again, but if I do- my answer will be TURP!

A Banterings

Everyone agrees that outside forces have taken their toll on the doctor patient relationship. We also all know that the system will NEVER return to the paternalistic system that doctors once enjoyed. The solution is to put patient centered care into overdrive. We need to apply the consumer model to healthcare, make the customer (patient) always right.

This will actually make conditions BETTER for doctors. You see, a GOOD doctor will take the time to educate and convince the patient on the best course of action. If that course does not meet the patient’s goal or definition of quality of life, a GOOD doctor will collaborate and help reach a happy medium.

Obviously, those paternalistic dinosaurs will not be able to survive a system of such extreme climate change. We are beginning to see them faltering now with the transition into the ACA and EHRs. With the patient as the one choosing, they will be ultimately responsible for the decisions that they make and the doctors responsible for ensuring that they have been adequately informed of all the options and the pros and cons.

This will also give doctors more time with patients. Look at all the financial service companies and how they are moving to a model that gives advisors more time with clients. That progression will naturally follow with doctors as well. Just as with any client base, there are going to be success stories and failures. Only, the fault of the failure will be upon the patient (unless the doctor did not properly inform the patient of options and consequences.

What the medical profession has failed to realize that despite what the profession deems good healthcare, it still must function within our society and must meet and be tempered by society’s expectations, norms, and laws. For example, there is a definite advantage to an annual physical where the doctor tells the patient to undress and the patient remains that way throughout the entire physical (dare I say the European model…). Yet, society does NOT tolerate that here in the US. Even patients who prefer this type of physical have been told by doctors to “put on a gown.”

Why has this changed? Society’s expectations and definition of human dignity. Despite the obvious scientific advantages, healthcare MUST conform to societal norms. Tuskegee was a glaring example of the conflict of what the healing profession thought was acceptable coming in direct conflict with societal norms and mores.

There will be those that balk at this notion citing their years of training, professionalism, even to the point of insulting patients by saying, “if you [patients] know better than doctors, then don’t bother coming…” This is not an insult to your learning or profession, it is actually an insult to patients to assume that all patients must accept YOUR values in place of their own.

Indeed society is responding to this unwillingness on the part of doctors to conform with societal expectations and norms. Although doctors do not like discussing the issue, for years hormonal birth control had been tied to unnecessary pelvic exams (and still does although not as prolific). Society is starting to authorize pharmacists to prescribe OTC hormonal BC. Planned Parenthood has developed an “app for that” as well. NPs and PAs are taking over the rolls once filled by PCPs.

The harsh reality is that the system IS changing. Doctors can either let it be changed by government, insurance companies, and corporations, OR they can elect the patient to be their leader. When society has the choice between doctors arguing for a return to paternalism OR government and business having to regulate and control doctors to protect patients, WHICH SIDE DO YOU THINK SOCIETY WILL (HAS) CHOOSE?

The only way to break the system of change is to do the unpredictable, and that is to succeed power to the patient entirely. In return, patients will return the better working conditions of more time, less paperwork, better compensation, etc. that doctors once enjoyed. The practice of medicine can be fulfilling once again.

Here is a perfect illustration of this concept from the movie, “Pirates of the Caribbean: At World’s End.” Think of Jack Sparrow as a representation of doctors in today’s society, Elizabeth Swann as the embodiment of patients, and East India Trading Company as government, healthcare corporations, and insurance companies.

King of the Brethren Court, was the elective monarch and leader of the Brethren Court. According to the Pirate Code, the King was holder of a great amount of power, and would lead the pirates around the globe. To be elected Pirate King, the plurality of the Pirate Lords were required to vote on a single candidate. This process was fraught with difficulty as it was common for each Lord to vote for themselves.

A new King was elected, when Jack Sparrow called for a vote and, while the other Lords voted for themselves, he changed the balance by voting for Elizabeth Swann. Elizabeth was elected King, thereby giving her power to vote for war against the East India Trading Company.

In the end, Jack Sparrow achieved his goals by giving away his power. In fact, it was an exercise to show the power that he actually held by giving it away. He knew that his power still remained with his skills and knowledge, not in the title of king or captain. It is his hubris that is his tragic flaw. It is only when he learns (uses) humility that he is most successful and achieves the life that he desires.

But the profession can continue to do the same thing that it has done for the last 100 years…

“Insanity: doing the same thing over and over again and expecting different results.” – Albert Einstein

Thomas D Guastavino

Newsflash:
1) Doctors were never as “paternalistic” as you think, unless thats what the patient wanted. That was a sure fire way to get patients mad at you and most physicians knew it.
2) Treating the patients as “customers that are always right” and “succeeding the power to the patient” can get you in a lot of trouble. If we were to follow that to the letter we would have a much bigger opioid addiction problem, way higher levels of unnecessary testing and a much worse problem of antibiotic resistance, to name a few.
3) A GOOD educator requires a WILLING student. Non-cooperation and secondary gain are a much worse problem then you think. There are many patients whose “goal and definition of quality of life” is a big insurance settlement.
4) The effects of the ACA and EHR are proving to be decidedly negative
5) The “unpredictable” (more like unintended consequences) have already happened in the form of avoidance of high risk, complicated or uncooperative patients is already happening.
I could go on but I have made my point.

southerndoc1

“This will also give doctors more time with patients”

You have absolutely no idea what you are talking about.

MuscleSpasm

Yes, I did need to shop around for PT. Hospital owned facilities charge $200-$400 per session (that is their “estimate”) but other places charge for it as an office visit, which is a copay, and mine is $60. Even at that, several sessions at $60 certainly adds up. Finding out these prices to begin with was not an easy task. I have an “approved” number of visits at that price, so I am doing PT at home and follow up at the office until I hit my number of preauthorized visits.

HJ

Your insurance negotiated price was $200-$400 or the cash price?

When I was injured, my doctor recommended a PT that had extensive knowledge in the type of injury I had. Should I have comparison shopped for a cheaper one?

MuscleSpasm

$200-$400 was what I paid cash per session at a hospital owned facility. I go to a sports med doctor office for my current PT and am charged for an office visit. $60 per session. Big difference. If you are going to a hospital owned facility you should look into other options. My insurance company gave me a list of approved providers in-network that charged PT as an office visit.

MuscleSpasm

The insurance company negotiates different rates with different providers. I had no troubles whatsoever with the MRI that I got. It was also read by my ortho as well as an interventional radiologist. I certainly didn’t need to spend that $1000 more.

buzzkillerjsmith

I’m very sorry to hear about your wife and hope she and you are doing well.

Re: the “greedy doctors” comment, I happened to be in a fast food place in John Day, Oregon, last summer when an old guy started talking with a woman about his health problems. The exchange ended with the woman commenting about how it’s all about money in medicine. Everyone there heard.

You’re a real class act, lady. Trashing our lives’ work, with our tens of thousands of hours spent helping other people when we could have gone into finance instead.

MuscleSpasm

For the record i have had, for the most part, great experiences with my doctors, and physical therapists and pharmacists….the people on the front lines. I do believe they have been there to help me, and I respect them and genuinely like many of them. I do not blame them for the financial disaster that is today’s health care arena. They don’t set the prices. However, in other respects, yes medicine is about money. Big hospital systems, pharmaceutical companies, insurance companies… In their world it IS about money. Like it or not, you are a part of that system.

MuscleSpasm

I had the MRI first and then the $360 PT. they were experienced in my condition and weren’t able to help me. I still have that same pain almost 4 years later. In that time I have spent about $11,000 of my own money on my health problems. I don’t have blue ribbon insurance and am single, I don’t have unlimited resources. I am in PT now for a different injury. There is absolutely nothing wrong with choosing a more affordable option. I don’t rely on my PT for diagnosis and treatment, I rely on my doctor for that. If you can afford the most expensive of everything because it’s the most expensive, then good for you, but that is not my reality.

Thomas D Guastavino

OK, a good start. At least someone is acknowledging that these questions need to be answered before any “fix”. Heres mine:
1) A medical “error” is a clear cut identifiable action (verb) on the part of a provider that was the proximate cause of a negative medical event (noun). So, a post-op infection is a negative medical event, not an “error”. If it is found that the instruments were improperly sterilized that would be the medical error.
2)The principal cost driver of health care is rapidly expanding medical technology coupled with the believe that that technology should be available to everyone.
3) The chief cause of controllable “unnecessary care” (I don’t consider CYA unnecessary) is a lack of knowledge and understanding of one is trying to achieve by applying that care. So, if a provider gets an MRI for everyone with knee pain they may not understand when it appropriate to get the MRI.
4) The chief causes of a poor medical outcome are:
A) Death is inevitable. Even if you successfully treat one thing eventually something else crops up that you can’t treat.
B) The human body is a complex machine that we are trying to reverse engineer. Knowledge advances all the time. Some treatments when they are new can have side effects that are worse then the disease itself. Traditional chemotherapy comes to mind.
C) Non recognition by the patient that they are a partner in their care. If someone gets lung cancer who has refused to quit smoking it is not the physicians fault.
Provider “errors” are way down the list.
There you go. Discussion?

Vic Nicholls

Yes – do you have resources for your items. I don’t ask to insult. I keep a lot of resources and use them to reference and modify beliefs (or solidify). Sometimes the beliefs are mine and sometimes they are others.

The problem is it beats “someone said on the internet”, so that’s why I ask. My doctors are used to be giving research for what I do and I want to keep that trust by trying to stay in that realm.

MuscleSpasm

Your posts are well-written, they just don’t make any sense. No offense.

MuscleSpasm

Like I said, there were no problems with the scan. I didn’t have to do it over again. Later when I consulted with an interventional radiologist who read the scan in front of me, and explained it to me, there were no problems. Hospital systems price-gouge. I wish it weren’t true. I wish we lived in a country where people were charged a fair, reasonable, and transparent rate for health care, but that is not a reality. Just saying.

Thomas D Guastavino

It looks like you ignored pretty much everything I said in in favor of the same preconceived narrative that has led to the numerous ill-advised solutions we have today. This is why we are getting nowhere with health reform.

Vic Nicholls

I dont think so. I think some of the items could be modified a little, but I’ve seen on sites and lists where doctors refuse to include patients, admin does it too, and why there is so much carping is that a system that is supposed to exist for us still refuses to include us at the table.

If you are ignoring the values and social mores of the customer base, they’ll come back at you. One way or another. I’m just frightened that it will be someone who brings in weapons or the like. We can all be very passionate about issues, just when I’m concerned over physical safety, we shouldn’t have to do that.

Thomas D Guastavino

Strange thing about the “values and social mores of the customer base”. Once you cut through the skin everyone is pretty much the same.

Vic Nicholls

Yes, harmed patients all agree there needs to be massive change in attitude and every system person/element.

Thomas D Guastavino

Does that include the patients themselves?

Thomas D Guastavino

Does that include the patients themselves?

Vic Nicholls

Frankly there are more professionals that need to change attitudes than patients.

Vic Nicholls

Society has long realized that what doctors think and society things are two different things. With the advent of the internet, we can now see medical research & see how admin/lawyers/govt reacts and see how bad things are. Yes, the paternalism in medicine has to change along with the refusal and responsibility to take the blame for errors, mistakes, etc. When a doctor tells me ‘you know I don’t like it when you do that’, that says a lot about an attitude that should never happen. That sort of control and attempting to control others through gaslighting, blacklisting, etc. has to stop. There are well too many instances of doctors out of control. Look up Michael Swango, Christopher Dunstch. Are you willing to tell the patients families who were murdered your response? Go up to them personally and say it was their fault? Tell us patients, as Randy was told, by a part time MD blogger on this site that you deserve bad care for basically not kissing the ring and feet and whatever else of your MD?

Thomas D Guastavino

“Society has long realized that what doctors think and society thinks are two different things” Wow. And you wonder why good doctors are leaving. Do you honestly believe that physicians “murdering” patients is typical of the profession as a whole? Unbelievable.

Vic Nicholls

When health care professionals let things go, let errors go, without doing a “Courage Eduardo” or David Ring fess up, that is what peoples’ experience is: you all will do anything to silence and keep silent, allowing people to be harmed, before the profession does anything about problems. Small or large.

Most sad.

buzzkillerjsmith

Happened to hear them? The whole damn place heard them.

My stress level hovers around zero.

I second-guess my career choice for other reasons, not because of some silly woman in John Day OR.

Vic Nicholls

BK, I have to agree with LC in this one. Everyone is entitled to their opinion. Frankly I can pull a lot of reports that show it is about the money. It is that way for admin personnel and some docs also. When you get a bonus for X patients and then another bonus+A for Y patients, there is going to be question on that.

When the biggest issue we see from docs is not how to fix the system and make it safer, its about pay and work hours, well what do you want? I mean if the profession as a whole carps on that, we’re going to associate that with the profession.

That’s not a dog on you, just kinda trying to state the obvious from a patient point of view.

Vic Nicholls

Excellent job. I’m sort of behind in answering. Thank you. Enjoyed this and it does work for me too.

Thomas D Guastavino

Her is where your logic is way off course and why you are not only proving my point you are demonstrating why health care is falling apart. You state, “who decides what is a good outcome”. I have been saying all along that how can any real solutions be found if the parties involved cannot agree on the basic parameters? Eventually the parties get up and leave the table.
Lets take your your “DNR” example. You conclude that physicians are trying to inflict their belief system on terminally ill patients you are totally naive about how this came about and ignoring the real problem that physicians have been screaming about for years and that is the tort system. Physicians would love to have a binding, clear cut DNR agreement but try living in a system where some fourth cousin from 1000 miles away can suddenly show up with their attorney blow the whole thing up.

Vic Nicholls

“Her is where your logic is way off course” um no, what they’re describing is the huge disconnect between what patients want and what docs want. Too much paternalism, we are going to get our foot at the table.

Witness the SIDM list where NO patient or patient harm groups, Consumers groups, are invited to the table. Why? We refuse paternalism, of forcing your belief systems on us.

Thomas D Guastavino

OK, one more time. If there is a huge disconnect between what the patients want and docs want, who do you blame?? That is the entire point of my original post.

Yes, and healthcare exists IN society, hence society ultimately decides what is acceptable and what is not. Society has changed its position from accepting what physicians define as good healthcare to what patients define as good healthcare. Those are the new rules. The more that healthcare resists, the more things like the ACA and EHR that will be imposed upon the system to regulate it. If physicians would have accepted what society asked for in the first place, physicians would still be enjoying their autonomy.

Again, society is finding alternatives. Look at how CVS is shaping guidelines for cholesterol drugs.

To quote the Borg, “Resistance is futile…”

Thomas D Guastavino

In case you had not noticed you cannot “impose” your will on those who do not agree with you. Resistance is only futile when someone tries to use overwhelming force and the last time I checked this is still free society. If society is “finding alternatives” you are more then welcome to try just as long as you take full responsibility for the outcome.

Vic Nicholls

Why not? Doctors did it for years? “Turnabout is fair play”. Now that it is getting done to docs, they’re screaming like we are.

Patient Kit

I don’t really understand your position on this. While I agree that most patients no longer want old school paternalism from their doctors, at the same time, doctors’ purpose is not merely to fulfill the wishes of and follow the directions of their patients. Doctors know much more about medicine than I do and I know much more about myself and what’s important to me than my docs do. It’s not a power struggle for control between doctors and patients. It should be a true partnership with doctors and their patients working together, not against each other. If you have a doctor who you can’t work with in partnership to try to achieve agreed upon goals, it’s time to look for a different doctor. You make it sound like war between doctors and patients. Thankfully, that has not been my experience at all with my doctors.

Vic Nicholls

PK I think what they’re referring to is common sense vs. a blanket statement in every case. Just like ‘the customer is always right’ isn’t a blanket statement and should have some common sense with it.

Thomas D Guastavino

So you have placed the blame almost entirely on the physicians. So be it. There is only one thing you said that I agree with and the is that good docs are leaving and not for the the reasons you think. Someday the all the “good doctors” are gone maybe you will rethink your thought process.

Vic Nicholls

If you noticed, admin & the like were included in the whole statement. I did that on purpose.

There are always going to be “good” docs and “bad” docs, same as patients. Whether or not there will be good admin like Paul Levy, that remains to be seen. 🙂

I have a positive, team working relationships with docs now, that is no thanks to blacklisting, gaslighting and the like from a previous doctor. The ones I have dont have a problem with me because our attitude is that of a we work together/listen to each other relationship. We support each other. We’re honest.

I also have experienced many docs can’t deal with patients who can read UpToDate and the like. A patient who questions, thinks, brings research to the table, is not the enemy, it is ego, attitude, that is.

Thomas D Guastavino

You have far to many replies for me to respond to individually. Please review my replies to “A Banterings”.

Vic Nicholls

Bingo.

Thomas D Guastavino

“When all the docs are gone we will import docs with H-1 bias who are willing to work with patients” Isn’t that the same attitude plantation owners had in the past when dealing with slaves? Their replaceable and expendable so there is no reason to treat them fairly as we can easily import more. If the ones we import are not happy we can get rid of them and import more. After all, we have the law(yers) on our side.
There you have it, my fellow physicians. The reward for years of hard work, sacrifice and complacency for not standing up in the past when things started to go downhill. My advice: Keep being as honest and dedicated that I know the vast majority of you are but get as far away as you can from non-cooperative and demanding patients as well as patients with unrealistic expectations. Stay away from emergency rooms. Super specialize so you can become highly proficient and efficient at delivering the best care you can in such a narrow field of focus that they have to come to you to get the specialized care they need as well as being in a much better position to defend yourself against the continual runaway tort system. Finally, always have an escape plan. Be able to get out quickly with as little fanfare as possible. This is the only way you will survive todays hostile environment, prevent burnout as well as keeping your sanity.

Vic Nicholls

Isn’t blacklisting and gaslighting, stalking patients (or having your patients gang stalk them), sending lawyers after them when they’re not suing you or have never sent a lawyer to them, trying to manipulate and control patients or seek revenge for telling them that the behavior (among others) must stop?

There are physicians that agree with that behavior. If you believe that is being demanding and unrealistic, I think you would have a clear majority of psychiatrists and psychologists who have listed such behavior as not being positive, normal, or one that a medical professional (of any degree) should display.

Thomas D Guastavino

Thank you once again for proving my points. I wish you luck in finding the type of provider that will agree to absolutely everything you demand.

And what happens when I do not agree with what you are saying because it does not fit my life goals? You withhold treatment? If you are wrong and cause me harm then what obligation do you have to me?

Yes there are those that game the system to feed their addictions. I also resent the implication that you make that I am a narcotics seeker. That is an attempt to bolster your position. I am all for cooperation, but the question of what to do when there is an impasse?

It seems that your answer is dump the patient.

And what of all the doctors who do not listen to their patients or tell them they are somatoform symptoms only to have a concrete diagnosis years later when the patient finds a physician who will listen?

How many times do I have to say this.? The patient-physician, or for that matter any human relationship, only works when there is mutual respect and cooperation on the part of both parties and one is not trying to impose their will on the other. If you do not agree with what I am recommending you are free to seek another opinion with whomever you choose. If you feel a physician is not listening then dump them and find another physician. Likewise, I reserve the right to dump you as my patient if you are not following what I am recommending. What is the point of continuing a relationship like that? Thats the beauty of freedom of choice. You seem to be advocating a dictatorship. As far as legal action action is concerned I doubt you were ever on the receiving end of a meritless lawsuit because if you ever were you would not be so quick to recommend that option.
By the way, I love Hershey bars but I am not diabetic. I would be happy to add a few to my diet if you agree to a bite of reality sandwich which you desperately need.

Vic Nicholls

The problem sir, is that I’ve had doctors who didn’t respect the patient, wouldn’t cooperate, and imposed their will (one of the phrases that caused jaw dropping of people was ‘you know I don’t like it when you do that’). That sort of relationship doesn’t work nowadays, and would be considered a controlling/abusive type of relationship.

One doc said if I gave you this referral you wouldnt see that doc. I said yes I would, out of respect for you. The doctor has been a team player, team builder, and a human being. I’ve gone to others on their recommendation because of those attributes.

I’m not sure you understand what it is like to be a patient. You can’t just drop docs and go elsewhere. Maybe in some fields or some areas, but that isn’t true in a lot of America.

Thomas D Guastavino

I have only one thing to say. Be careful what you wish for.

Patient Kit

“…For that kind of money, I expect you to follow the patient’s instruction….”
__________
You can’t be serious. Can you? I’m a patient who is very engaged in my medical care. My docs all seem to like working with me even though my insurance hasn’t always been the highest paying. Even when I was covered by Medicaid, my docs went out of their way to help me and I deeply appreciate all that they have done for me. I’m not passive. I ask plenty of questions. I always need to understand my doc’s “why”. I’m not complacent but once my doc and I agree on a plan, I am cooperative and compliant.

But I have never expected my docs to follow my instructions. I expect them to listen to my concerns and answer my questions and take the time to explain why they are advising the treatment plan they are recommending. I expect respectful discussions with my docs during which we both listen to each other. If you are convinced that you know so much more than your doctors, why do you even consult with doctors for medical advice?

Vic Nicholls

PK remember, this is the internet. I understand the intent coming across. I don’t think you picked that up. 🙂 They meant that in a good way, not in negative terms. The first thought comes to mind is I wouldn’t expect a doc to give someone 100 painkiller pills for 10 days, but I would expect them to listen to me if I bring in medical research on a problem.

Common sense …

Thomas D Guastavino

Are you kidding me? Show me the law that says a physician must comply with everything the patient wants. Answer this. The law says I can only dispense 30 oxycontin at a time yet the patient is demanding 60. You are saying I have to comply with the patient?? On top of that you believe if there is continued “dissonance” we need “more laws and regulations” Whats next, forced labor camps for physicians? The last time I looked this is still a free society where rule of law prevails, not rule of the individual.

Vic Nicholls

I dont think complacency as much as paternalism. Again, common sense, I dont think that opiate addicts would get sympathy if a doc said no. I would not expect a doctor who did a Christopher Duntsch on his patient to have any one support that. The thing is, admin & other docs did support Duntsch.

It is outlier stories that are becoming more common, like the “butt slapping” surgeon and the gas passer who talked badly about a patient and falsified records, more and more of those stories are what people need to see changes in the system and professionals for.

Vic Nicholls

Perfect. That sums up how harmed patients feel.

Vic Nicholls

🙂 I was actually referring to our good buddy Thomas G. 😉

Thomas D Guastavino

In case you had not noticed I am the author of this piece. The point was that based on my observations the majority of health cares problems stem from providers trying to interact with misguided attempts to “fix” the system based on false assumptions and conclusions as to why our health care system is not functioning properly. I predicted that many people would blame physicians and that clearly includes you and others who have responded. I am advocating a physician-patient relationship realationship based on mutual respect, undestanding, and freedom of choice giving both parties a way out if things go wrong, while you are advocating a patient based dictatorship, even going so far as to try and “force” physicians to comply and if they don’t try and import compliant physicians from overseas.
Now I ask you. Which system is more likely to succeed.?